Abuse of tertiary referral hospitals

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    I work in an ICU of a university hospital and they are a tertiary referral center for a large area (only university hospital on a population of roughly 3 - 4 million habitants). We serve as a level I trauma center, transplant service, extensive cardio, the works.

    So for the last four nights a level II trauma center from a neighboring city sends over four referrals and they all ended up in my ICU. Every time it was the same story: "we intubated the patient but we have no room in our ICU". Side note here come the details on the patients:
    #1: pCO2 - 75 mmHg, pH 7.25 COPD Cold 3 + Parkinson intubated due to respiratory failure after receiving 15 L O2 by NR-mask. No non-invasive ventilation tried.
    #2: aspiration pneumonia after numerous CVAs, patiŽnt with a baseline GCS of 8/15 at her better moment intubated, side note (literally from the transfer script): "Family is very disgruntled about the situation causes a lot of trouble"
    #3: another carbonarcosis COPD Cold 4 intubated, no non invasive ventilation tried. Intubated. Has a very poor cardiac reserve as well.
    #4: First telephone advise asked: patient without a BP or pulse if we have room in our ICU for this patient. So when we tell them to do CPR and get her stable and all the lines in and we'll come to collect. Their reply: "but we can't do CPR she is talking"... *AARGGGH*
    This patient comes in chronic renal disease, bilateral amputation of the legs, blind, IDDM, morbidly obese 100 kg on the remaining 130 cm length. This one was not intubated but was "very hypotensive" but corrected after 500 cc of colloids. ER nurse tells me that when he went to collect the patient and the ER nurse from the other hospital said to the patient as they were leaving "madam you are a ******* demanding *****".

    So I think these patients were better off at our hospital then the other one. It sucks a bit that all these patients will probably be vented for weeks and the other hospital won't accept them back (and I doubt any of the patients want to go back).

    But here comes the catch. Our MUG (which is the prehospital care team from our hospital) are called in for a isolated neurotrauma close to that city. And they intubated the patient and contact the level II trauma center if they can receive the patient (they had no knowledge that for the last 4 nights they had "no room" in their ICU). They get the answer "sure always room for a nice trauma patient". When the ER called for their nightly gossip and I heared this I just wanted to explode.

    I hate how some hospitals always abuse a tertiary referral center. And our medical director of the ICU has declared that under no circumstance are we allowed to refuse: children, traumas, cardio, intoxications and referrals from other hospitals (I wonder what is left to refuse). There is always room even if we have to make extra beds.
    One more nightshift to go I wonder what they'll send over tonight.
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  4. 0
    Wow, it sounds like you certainly are receiving some major dumping from that other hospital. Out of curiosity, how does funding for your hospitals work? I just tried looking up your health care system using google and was able to glean that your country has a hybrid private/public system. Is the referring hospital private? I read that while there is some minimum mandatory insurance coverage that there is also supplemental coverage that I imagine would reimburse better (particularly being the mentioned patients sound unlikely to be able to pay their portion given their poor health and probable inability to work).

    #4: First telephone advise asked: patient without a BP or pulse if we have room in our ICU for this patient. So when we tell them to do CPR and get her stable and all the lines in and we'll come to collect. Their reply: "but we can't do CPR she is talking"... *AARGGGH*
    That made me laugh so hard I was afraid I was going to damage to the wound where I had my tooth pulled today.
  5. 0
    Good luck finding anything out about the financing system, I'll try anyway. Remember our small mini country is ruled by three governments at the same time that all want something to say in the health care system.

    While it is true there are government funded and private hospitals in practice this difference is barely noticeable (other than that the government funded ones can't go bankrupt but have to follow government guiding). The private hospitals generally have better working benefits for their personel.

    Say 10 - 20 years ago a public hospital was required to administer emergency care but could force you to go to a government facility if your problem was non-emergent or make arrangements to transfer you there once stabilized. They could only force you if you were on welfare. Quality of care in these government hospitals was/is excellent as well and provide most major services for patients.

    The University hospitals can be either private (as mine is) or public. I checked for the Dutch speaking part of the country and out of the three university hospitals two are private and one is public. Even in the past people on welfare were allowed to be referred to university hospitals for specialist care. The referring hospital above (the level II trauma center) is a private hospital as well.

    The major player in our health care system is an organization called RIZIV. They are the "watchdogs". They've come up with codes for anything you could encounter while in health care. To give an example when a patient comes in in a full code we have to register: the intubation, the ventilation, the placement of the central line, arterial line, swan ganz, the monitoring non invasive, monitoring invasive, monitoring cardiac output, therapeutic hypothermia, amount of shocks given (both synchronized and asynchronized), placement of foley, placement of NG-tube, administration of chest compressions, EtCO2-monitoring, every EKG we take, assessment of arterial lines, monitoring of ventilatory parameters... etc. And afterwards all these interventions are booked via different RIZIV numbers and every number corresponds with a fixed amount of money the hospital is allowed to charge for this.
    This is charged to RIZIV and RIZIV on their turn charge the patient or their insurance or the OCMW (the welfare organisation). And the insurance companies and OCMW decide which RIZIV codes they'll pay based on the type of insurance.

    So when we place a Swan Ganz we charge for placement of central line (the introductor), heart cathetherization, monitoring of cardiac output and invasive monitoring so that's 5 bookings. Now some of these interventions are payed for by RIZIV for a limited time. E.g. invasive monitoring is payed for only 5 days, ventilation of a patient is payed for only 21 days. After 22 days you have to contact the MD of the RIZIV and explain why you are still ventilating a patient after 21 days and generally they'll allow you to bill longer periods (as our center is acknowledged as a weaning facility and center for chronic ventilation). On top of that the first day receives more money than the remaining period this intervention was in place.

    So what do most referring hospitals do they'll place all the lines etc (they can bill it to RIZIV and receive the money) and get more money because they initiated all monitoring (they get payed day 1 fee) and when we take the patient in we can charge only day 2 and beyond fees (which is considerably less). I think this is the reason a lot of chronic cases/patients are referred because they'll cost more than they'll make. Or the other typical event around day 20 the referring centers start asking for a transfer because of "weaning failure" but ironically you find no evidence of any weaning attempt.
    E.g. if you aren't allowed to bill ventilation day 22 for example (because you screwed something up big time and your patient is ventilator dependent because of preventable complications - and naturally RIZIV sayed nono!) you just need to extubate the patient for 24 hours and a new period of 21 days will activate. Since this practice was very popular in the unscrupulous hospitals in my country the RIZIV will generally pay for longer periods when asked.

    If a hospital wants tot try novel therapies that aren't RIZIV acknowledged you have to beg them to pay for it otherwise it is all expenses paid by the hospital. We had this problem in the past when LVAD's etc. weren't acknowledged yet and the hospital payed the majority of the costs, RIZIV payed barely anything and patients/family had to sign a declaration to pay a fixed amount per day (I believe it was around 16 US dollars (€10) per day on LVAD). That's the problem with RIZIV they are a bit slow getting registration for novel therapies so in the beginning the hospital has to bear most of the costs (so for years our hospital payed for LVAD's, coiling of aneurysms and AVM's, endovascular prothesis, etc). And some interventions are limited to an amount per year. E.g. the center will get permission to place 10 ECMO's per year and 40 LVAD's if they go over this number the costs are again for the hospital to bear.

    If people are uninsured then the OCMW (the welfare organization) decides what medical expenses are payed for and not. Most therapies will be payed for, but some will be refused. E.g. I remember an illegal immigrant of 18 years old that suffered from severe heart failure and we wanted to place him on LVAD and OCMW refused this and would only allow for a direct heart transplant. I and in the process the guy was granted legality and housing for post-transplant care. So this boy ended up on the high urgency list and received a lesser quality heart.

    As I said RIZIV is a watchdog as well and they'll do crosschecks between hospitals. And say you are billing more monitoring for post operative surgery XYZ than another hospital you can expect a reprimand from RIZIV demanding an explanation. And they'll monitor everything like subscriptions for trade name medicines when generics are available, too many diagnostic testing on common problems, etc.

    So that's our medical system in a nutshell. Half of the time it's being creative with numbers ^^. I remember this poor guy that was shocked 126 times which I checked and rounds to about 100 US dollars per shock
    Last edit by BelgianRN on Feb 22, '12


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